Healthcare Provider Details

I. General information

NPI: 1902144504
Provider Name (Legal Business Name): MATTHEW CURTIS DENRYTER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2013
Last Update Date: 05/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15855 19 MILE RD
CLINTON TOWNSHIP MI
48038-3504
US

IV. Provider business mailing address

1574 LARKMOOR BLVD
BERKLEY MI
48072-1926
US

V. Phone/Fax

Practice location:
  • Phone: 586-263-2374
  • Fax:
Mailing address:
  • Phone: 248-421-0121
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704252473
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: